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Carcinoma Showing Thymus-Like Elements Invading the Trachea

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Carcinoma Showing Thymus-Like Elements Invading the Trachea View metadata, citation and similar papers at core.ac.uk brought to you by CORE Brief Communications provided by Elsevier - Publisher Connector Carcinoma showing thymus-like elements invading the trachea Marco Alifano, MD,a Mohamed Sadok Boudaya, MD,a Carmen Dinu, MD,b Habiba Kadiri, MD,b Jean-François Regnard, MD,a Paris, France arcinoma showing thymus-like elements (CASTLE)removed is secondarily under jet ventilation. A termino-terminal a rare cervical tumor. Approximately 30 casestracheal have anastomosis was performed after laryngeal and tracheal been reported in the English language 1 Inliterature.release with dissection of both mainstem bronchi. 1985, Miyauchi and colleagues2 reported the first se- Pathologic examination (Figure 1) showed a tumoral prolifer- Cries dealing with this type of tumor. Although generallyation thought invading to the tracheal cartilage (without involvement of the have a less-marked malignant behavior compared with mucosa),thyroid the lower pole of the left thyroid lobe, the left superior carcinomas, CASTLE may progress and result in death. horn of the thymus, and the sternothyroid muscle. The surgical margins were free. Nodal metastases were found in 4 cervical Clinical Summary lymph nodes. At light microscopy, tumor growth in the form of A 63-year-old woman had anterior cervical swelling 6variably months sized islands separated by thick fibrous trabeculae was before admission to our unit. Assessment in another institutionobserved. byCytoplasm was abundant and eosinophilic, whereas nu- ultrasonography and computed tomography (CT) scan showedclei werea oval with distinct nucleoli and granular chromatin. Nu- tumor close to the lower pole of the left thyroid lobe,clear causing atypia wasright moderate, and some areas of necrosis were observed. and backward tracheal dislocation. There were no enlargedMitotic lymph figures were also present. The cells were immunohistochemi- nodes. The lesion was misdiagnosed as a thyroid goiter,cally KL1andϩ, EMAϩ, CD5ϩ, CD117ϩ, chromogranin Aϩ, and cervicotomy was planned. At surgery a tumor was foundTTF1 infiltrat-Ϫ. ing the strap muscles and trachea, but independent of theThe thyroid postoperative course was uneventful. Adjuvant cervicome- and thymus. No resection was attempted. Because of thediastinal absence radiotherapy (55 Gy) was performed because of the of a preoperative diagnosis and inconclusive data from presencethe frozen- of nodal metastases. The patient showed no sign of section examination, only biopsies were taken. The pathologicrecurrence at the 6-month follow-up. diagnosis was thymic carcinoma. The patient was referred to our institution for subsequent management. Discussion A novel CT scan was consistent with tumoral progression,CASTLE is an extrathymic tumor occurring at the cervical level in compared with the first CT scan performed 3 months thepreviously. trajectory of embryonal migration of the thymus (between the Fiberoptic bronchoscopy showed an extrinsic compression mandibularof the angle and the retrosternal region). The lesion may arise trachea starting 3 cm caudally to the vocal cords andeither involving inside the4 thyroid gland (in this case it was located in the tracheal rings. 18-FDG positron emission tomography showedlower portionan of the lobes) or in the latero-tracheal region. isolated hypermetabolic focus corresponding to the cervical tumor.In our patient, the tumor did not have any contact with the We decided to perform another surgical exploration. At thyroidcervico- at the time of the first surgical exploration. The spontane- sternotomy, invasion of the sternothyroid muscle and tracheaous evolutionby a of this tumor at 3 months was responsible for the 6-cm tumor was confirmed. The lesion infiltrated the uppersubsequent portion limited invasion of both the thymus and thyroid. of left thymic lobe and was in close contact with the lower aspect of the left lobe of the thyroid. An en bloc resection of the thymus, sternothyroid muscle, trachea (8 rings), and lower aspect of the left thyroid lobe was performed. For technical reasons, the tumor was removed en bloc with the cartilaginous portion of the trachea. The membranous part, which was completely free of the tumor, was From the Unité de Chirurgie Thoracique,a Service d’Anatomie et de Cy- tologie Pathologiques,b Hôpital Hôtel-Dieu, AP-HP, Université Paris V, Paris, France. Received for publication Feb 6, 2006; accepted for publication March 15, 2006. Address for reprints: Marco Alifano, MD, Unité de Chirurgie Thoracique, Hôtel-Dieu 1, place du Parvis Notre Dame, 75181 PARIS Cedex 04, France (E-mail: [email protected]). J Thorac Cardiovasc Surg 2006;132:191-2 0022-5223/$32.00 Figure 1. Gross section after formalin fixation. Relationships Copyright © 2006 by The American Association for Thoracic Surgery among the tumor (dotted arrow), cartilaginous portion of the doi:10.1016/j.jtcvs.2006.03.020 trachea (arrow), and left lobe of the thymus (double arrow) are evident in this section. The Journal of Thoracic and Cardiovascular Surgery ● Volume 132, Number 1 191 Brief Communications C o m pared with patients with thyroid carcinoma, patients with References CASTLE seem to have a better prognosis. However, CASTLE has a 1. Luo CM, Hsueh C, Chen TM. Extrathyroid carcinoma showing thymus- potentially invasive behavior, and invasion of neighboring cervicallike differentiation (CASTLE) tumor: a new case report and review of 2 3 structures is possible. In particular, ortracheal laryngotrachealre- literature. Head Neck. 2005;27:927-33. sections have been necessary to excise the lesion. The 2.extent Miyauchi of A,this Kuma K, Matsuzuka F, Matsubayashi S, Kobayashi A, invasion may sometimes prevent a complete1 orresection require Tamai H, et al. Intrathyroidal epithelial thymoma: an entity distinct surgically challenging procedures, as in our experience. The fromparietal squamous cells carcinoma of the thyroid. World J Surg. 1985;9: 4,5 128-35. invasion can involve the muscles, connective tissue, and 3.skin. Mizukami Y, Kurumaya H, Yamada T, Minato H, Nonomura A, Nogu- Nodal involvement is probably a negative prognostic factor,chi M, et al. Thymic carcinoma involving the thyroid gland: report of because it has been associated with the occurrence 3of locoregionaltwo cases. Hum Pathol. 1995;26:576-9. or systemic spread.1,2 Adjuvant radiotherapy is generally- advo4. Bayer-Garner IB, Kozovska ME, Schwartz MR, Reed JA. Carcinoma cated in case of nodal metastasis. On the other hand, withlocal thymus-like recur- differentiation arising in the dermis of the head and neck. J Cutan Pathol. 2004;31:625-9. rence is possible in the absence of nodal disease, thus5. Ahujasuggesting AT, Chan ESY, Allen PW, Lau KY, King W, Metreweli C. Carci- a role for systematic adjuvant radiotherapy because of the radio- noma showing thymic-like differentiation (CASTLE tumor). AJNR Am J sensitivity of this tumor.1 Neuroradiol. 1998;19:1225-8. A new technique for prosthetic reconstruction of the superior vena cava Antonio D’Andrilli, MD,a Anna Maria Ciccone, MD,a Mohsen Ibrahim, MD,a Federico Venuta, MD,b and Erino A. Rendina, MD,a Rome, Italy lthough the feasibility of resection and prosthetic re- eration. A right-sleeve pneumonectomy associated with resection placement of the superior vena cava (SVC) has been and prosthetic reconstruction of the SVC was performed. Patho- largely proven,1 the type of vessel reconstruction is logic examination documented epithelioid leiomyosarcoma. still an object of debate and the search for improved Twenty-nine hilar and mediastinal nodes were removed. Only 3 Atechnical devices is currently active. peribronchial nodes resulted at pathologic analysis. We describe a new technique for the construction of the peri- Case 2 was a 55-year-old woman who presented with an cardial tube that we have successfully used in 2 cases of recon- endoluminal tumor of the SVC with complete vascular obstruction struction of the SVC. for a longitudinal extension of approximately 7 cm, confirming SVC syndrome. The patient underwent radical removal of the Clinical Summary tumor by a complete resection and reconstruction of the SVC. A Case 1 was a 50-year-old man who presented with a large right metastatic tumor of an unidentified origin was found at the patho- pulmonary mass (11 cm in diameter) invading the carina, SVC, logic examination. No intraoperative or postoperative major complications oc- pulmonary artery, and superior pulmonary vein. Histologic diag- curred. Both patients are well and without evidence of disease 16 nosis achieved by endobronchial biopsy was mesenchymal prolif- months (case 1) and 13 months (case 2) after surgery. eration of uncertain behavior. After laser recanalization of the right main bronchus by rigid bronchoscopy, the patient underwent op- Surgical Technique From the Department of Thoracic Surgery, University of Rome “La The surgical approach was posterolateral thoracotomy in case 1 Sapienza,” “Sant’Andrea” Hospital,a Rome; Department of Thoracic and muscle sparing lateral thoracotomy in case 2. Surgery, University of Rome “La Sapienza,” Policlinico “Umberto I,”b After complete isolation and distal and proximal clamping of Rome, Italy. the SVC, the caval segment infiltrated by the tumor was resected Received for publication Feb 17, 2006; accepted for publication March 15, and vascular continuity was restored by interposition of a heterol- 2006. ogous pericardial prosthetic tube. Intravenous sodium heparin (0.5 Address for reprints: Erino A. Rendina, MD, Division of Thoracic Surgery,
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